PA.003 Patient History Check

Patient History Check

1.0Principle

To compare the current test results with previous records, to detect a possible error and, if applicable, to assist in the selection of appropriate blood products for transfusion.

2.0Scope and Related Policies

2.1Before a red cell product is released for transfusion, interpretation of current tests must be compared with the patient’s records to detect a possible error or a potentially dangerous situation and to provide an opportunity for appropriate action. This comparison must be documented for the following records:9.1

• ABO and Rh typing

• Previous transfusions

• Difficulty in typing

• Clinically significant red cell antibodies

• Adverse reactions to a previous transfusion

• Special transfusion requirements

2.2Previous transfusion records shall be reviewed. Previous results must be compared with current results and discrepancies resolved.9.1

2.3Previous admission records alone shall not be used to obtain the recipient’s ABO and Rh group.

2.4Record of transfusion, transfusion complications, antibody reports and information required for lookback and traceback purposes must be kept indefinitely.9.2

3.0Specimens – N/A

4.0Materials

Supplies:TML antibody records, files or computerized previous history

Request form or electronic order entry

5.0Quality Control – N/A

6.0Procedure

6.1Check for previous files or records. See Procedural Notes 8.1 and 8.2.

6.2Document the history check on the request form, work card or Laboratory information system (LIS).

6.3If no previous record is found, indicate “not on file” in the appropriate area on the request form and initial.

6.4If a previous record is found, compare the date of birth and, if possible, the hospital identification number on the request form and on the file.

6.5Check the following and record pertinent information:

• Previous ABO, Rh, antibody(ies)

• Difficulties in blood typing (antibodies to platelet or red cell antigens)

• Previous transfusion or pregnancies, if applicable

• Previous adverse reactions to transfusion

• Special blood product requirements, if applicable (e.g., irradiated, CMV negative)

7.0Reporting – N/A

8.0Procedural Notes

8.1There must be a specific procedure for computerized TML file/history check. Follow an established procedure for a computerized history check, if applicable.

8.2If a previous record is not found, check for previous family name, if known. In case of duplicate names, check the date of birth and identification number.

9.0References

9.1Standards for Hospital Transfusion Services Version 2 – September 2007. Canadian Society for Transfusion Medicine, 5.2.4, 19.6.3, Appendix A.